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Chapter 6
Using Behavioral Observation Audiometry to Evaluate
Hearing in Infants from Birth to 6 Months
Jane R. Madell

♦ The History of Behavioral Testing of Infants ♦ Diagnostic Audiologic Evaluation of Neonates

Noisemakers The Basics of Behavioral Observation Audiometry
Early Infant Hearing Screening Programs Testing Protocol of Behavioral Observation Audiometry
Infant Thresholds Other Factors That Influence Behavioral Observation
The Need for Behavioral Testing of Infants Audiometry Test Results with Infants
Adding Objectivity to Behavioral Observation
Audiometry

Numerous authors have posited the necessity for cross-

Key Points
checking physiological results with behavioral data by using
a battery of tests to determine hearing sensitivity (Bess and
• Auditory brainstem response (ABR), auditory steady
Humes, 2003; Gravel, 2000; Hicks, Tharpe, and Ashmead,
state response (ASSR), and otoacoustic emission (OAE)
2000; Jerger and Hayes, 1976; Madell, 1998; Northern and
testing provide critical information about the status of
Downs, 2002). Behavioral testing of infants 6 months and
the auditory pathways, but are not direct measures of
older is a well documented part of the clinical practice of
hearing.
audiology (ASHA 2004). Behavioral evaluation of infants
• Only behavioral testing can provide a direct measure of younger than 6 months is more difficult to achieve and less
hearing. well documented. This chapter will describe a behavioral
technique that can be used to successfully evaluate hearing
• When carefully performed, using appropriate criteria
in infants younger than 6 months.
(including changes in sucking as an indication of a re-
sponse), behavioral observation audiometry (BOA) can
accurately measure thresholds in infants younger than
6 months.
♦ The History of Behavioral Testing
of Infants
Nonbehavioral tests such as ABR testing, ASSR testing, and
OAEs are frequently used to assist in estimating peripheral
hearing in infants (ASHA 2004). Although these tests are an As early as the 1940s, attempts were made to develop be-
important part of the audiology practice, they are, in fact, havioral techniques to assess hearing in infants (Ewing and
not tests of hearing. The only true test of hearing is behav- Ewing, 1940, 1944; Froeschels and Beebe, 1946). Sir Alexander
ioral assessment. ABR, ASSR, and OAE measures provide and Lady Ewing used percussion sounds and pitch pipes to
information about the integrity of specific sites within the elicit aural reflex responses (eye blinks). Wedenberg began
auditory system (Delaroche, Thiebaut, and Dauman, 2004; infant screening in Sweden in 1956 using pure tones to
Gravel, 2000; Hicks, Tharpe, and Ashmead, 2000; Sininger, elicit the auro-palpebral reflex. Froding continued Weden-
1993). Only behavioral testing truly tests hearing, since it berg’s work using a small gong and mallet. Some clinicians
measures the response of the entire auditory system from used the infant’s ability to turn toward the sound to assess
the outer ear through the cerebral cortex. Behavioral tests hearing. Frisina (1963) reported that between 2 to 4 months
permit measurement of what an infant actually perceives; of age infants could turn toward a sound. However, Northern
so they are measures of functional hearing abilities. and Downs (1974) reported that head turning does not

54
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6 Using Behavioral Observation Audiometry to Evaluate Hearing in Infants 55

occur before the age of 6 months, and Gerber (1977) reported identified using these methods, many with less than severe
the average age of head turn to be at 7 1/2 months. to profound hearing losses were missed. In spite of all at-
tempts to improve test protocols, BOA continued to be con-
sidered “unreliable.”
Noisemakers
Noisemakers were the most common sound source em-
Infant Thresholds
ployed for early hearing tests. They were selected for testing
because they were readily available, simple and inexpensive, Because behavioral test protocols frequently did not reveal
and could be used in any setting (a sound room was not re- threshold responses, some audiologists proposed that re-
quired) and it was believed that infants would respond more sponses at 60 to 70 dB SPL be interpreted as normal hearing
reliably to noisemakers than to pure tone stimuli. The diffi- for very young infants (McConnell and Ward, 1967, Northern
culty with noisemakers is that they usually have very broad and Downs, 1984). However, others demonstrated that in-
frequency responses. Furthermore, their intensity is not easy fants hear at essentially adult levels (Berg and Smith, 1983;
to control even with practice exerting the pressure neces- Eisele, Berry, and Shriner 1975; Madell, 1995a, 1998; Olsho,
sary to make the sound, and stabilizing the distance from 1984; Olsho et al 1988; Spetner, and Olsho 1990; Werner and
the infant’s ear. Bove and Flugrath (1973), and Poblano et al. Gillenwater, 1990). Olsho et al (1984) Olsho et al, (1987b,
(2000) analyzed different noisemakers to determine their 1988), and Nozza (2006), reported that average behavioral
frequency responses so that responses to noisemakers could thresholds of 3-month-olds were worse than thresholds for
provide more useful information. Even if noisemakers can- young adults by 15 to 20 dB between 250 and 4000 Hz, and
not provide sufficient information to be used to assess hear- by about 30 dB at 8000 Hz. By 6 months of age, hearing sen-
ing, they can provide some gross information about how an sitivity in the high frequencies improves but thresholds at
infant responds to sound. Specifically, noisemakers can pro- 250 Hz remain elevated by about 15 dB. Thresholds improved
vide some evidence of an infant’s ability to alert to sound by 20 dB between 3 and 6 months. Olsho et al (1988) dis-
and localize to the source (Northern and Downs, 2002). cussed that the audibility curve of younger infants may differ
Before using any noisemakers, information should be ob- in shape compared with the curve of older infants and adults.
tained about the auditory signals they emit, including their It was assumed that this audibility curve difference was, at
frequency response and intensity. Results of noisemaker tests least in part, due to the characteristics of the external and
must be viewed with caution. For example, a noisemaker middle ears in infants. Arlington (2000) and Olsho et al
may have the bulk of its energy in the 2000 to 4000 Hz range, (1988) postulated that some of the threshold differences may
but also have energy at 500 Hz at 30 to 40 dB less intensity be related to sensory immaturity.
than the high frequencies. What can be surmised about the Gravel (2000); Hicks, Tharpe, and Ashmead (2000); and
infant’s response to this stimulus? It is possible that the in- Olsho et al (1987a,b, 1988,) use an observer-based procedure
fant hears the high frequency component of the stimulus, but developed by Olsho to reduce tester bias in evaluating hear-
it is also possible that the infant has a high frequency hearing ing in infants as young as 2 to 5 weeks. In this method, a trial
loss, does not hear the high frequency part of the signal, and consists of a sound or a no-sound interval. One or two
is responding to the low frequency component. trained observers watch the infant and make a determination
as to whether the interval contained a sound, or no sound,
based on the infant’s response. The observer receives feed-
Early Infant Hearing Screening Programs
back as to whether a sound is present. Once the observer
The first large-scale infant hearing screening program in the demonstrates a false-positive rate of less than 25% reliable,
United States was a citywide hearing screening project in testing begins. Hicks, Tharpe, and Ashmead (2000) used this
Denver, conducted by Marion Downs and Graham Sterritt in technique with two observers testing 2 - and 4-month-old
1964. They used a handheld noise generator that emitted a infants. They successfully obtained thresholds for 4-month-
90 dB SPL noise centered at 3000 Hz. Downs and Sterritt olds, but were not successful in obtaining thresholds for
(1964, 1967), Northern and Downs (1991), and Werner and 2-month-olds. Several authors evaluating hearing in infants
Gillenwater (1990) attempted to develop a standardized pro- report that results could be optimized by enhancing the test
cedure to assess an infant’s behavioral arousal, but a signifi- conditions. This enhancement included reducing visual dis-
cant number of false-positive test results made the testing tractions (Muir, Clifton, and Clarkson, 1989), using a salient
unreliable. Several authors have described techniques for as- auditory stimulus (Thompson and Thompson, 1972), rein-
sessing behavioral responses in infants, including observa- forcing desired behaviors (Olsho et al, 1987a, 1988), and
tion of eye widening, quieting, eye shifting, head orienting, using changes in sucking as the response criteria (Delaroche
limb movement, and changes in respiration. Attempts have Thiebaut, and Dauman, 2004; Madell, 1995a, 1998). Because
been made to calibrate the observer (Mencher et al, 1977; of the critical need to obtain reliable test results on infants,
Weber, 1969), to assess the state of the infant (Eisenberg, research in this area will need to continue.
1969), and to precisely calibrate the signal (Thompson and
Thompson, 1972.) A major problem with using the auro-
The Need for Behavioral Testing of Infants
palpebral reflex, the Moro reflex, or changes in limb move-
ment or respiration is that these behaviors are not elicited to Over time, the demand for infant hearing screening has in-
threshold stimuli, but rather are responses to suprathresh- creased significantly, so that many states have mandated
old stimuli. Although some infants with hearing loss were newborn hearing screening requirements. (See Chapter 4 for
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56 II Diagnosing Hearing Disorders in Infants and Children

a complete discussion of newborn hearing screening.) As neonates include immittance testing with a high-frequency
more infants survive and as hearing screening becomes more probe tone, auditory brainstem response testing (ABR),
universal, audiologists are being asked to assess hearing in auditory steady state evoked potential (ASSEP) and/or OAE.
very young infants who have failed newborn screening and Immittance testing assesses middle ear status, but does
to manage hearing loss when it is identified. One of the first not provide information about hearing. ABR and ASSEP pro-
steps in hearing loss management is the selection and fitting vide information about the auditory system’s ability to
of appropriate amplification. Hearing aid fitting requires an receive sound, but are not direct measures of hearing. OAEs
accurate assessment of the degree and type of hearing loss, assess function of the outer hair cells of the cochlea but,
with both ear and frequency specific information obtained by again, are not a direct measure of hearing. Information
air and bone conduction. about an infant’s ability to hear and attend to auditory stim-
Many audiologists feel comfortable testing hearing in uli can be obtained only with behavioral testing. For that
infants older than 6 months using visual reinforcement au- reason, no at-risk infant or child should be released from
diometry (VRA), but do not feel comfortable testing younger audiologic follow-up until behavioral test results are ob-
infants, developmentally delayed infants, or critically ill in- tained. (See Chapter 13 for a discussion of immittance test-
fants. If an infant fails a hearing screening at birth, hearing ing, Chapter 14 for a discussion of OAE testing, and Chapter
aids should be fit within a few weeks. Work by Apuzzo and 15 for a discussion of ABR and ASSEP testing.)
Yoshinaga-Itana (1995); Yoshinaga-Itana, Couter, and
Thomson (2001), and others have demonstrated that in-
Pearl
fants who are fit with appropriate technology before they
are 6 months old can develop speech and language skills
• Although ABR, ASSR, and OAE testing provides important
commensurate with their normal hearing peers, and that
information about the status of the auditory system, only
infants fit with technology older than 6 months, do not
behavioral testing directly tests hearing. For this reason,
catch up to those fit earlier. Sharma, Dorman, and Spahr
it is critical that audiologists have a behavioral technique
(2002) have demonstrated that infants who receive audi-
that is accurate for assessing hearing in infants younger
tory stimulation at a sufficiently early age have evoked
than 6 months.
potential latencies similar to normal hearing peers, but
infants who do not have sufficiently early access do not.
Behavioral testing allows the parents to participate in test-
ing by allowing them to assist in determining when the infant The Basics of Behavioral Observation Audiometry
is responding to a sound. If parents are provided with infor-
What Is Being Observed?
mation about what to observe, they can be active participants
in testing, facilitating acceptance, and understanding of hear- Historically, many behaviors have been used to assess hear-
ing loss (Gravel and McCaughey, 2004). Electrophysiologic ing in infants (arousal, limb movement, respiration changes,
testing, on the other hand, provides little for a family to ob- eye blink), but these behaviors have not proven to be suffi-
serve. It is clear that we must develop test techniques for ciently repeatable, and more importantly, they have not
evaluating very young infants that will provide the ear and been good indicators of threshold. The behavior most likely
frequency specific information necessary for the evaluation, to provide threshold responses is a change in sucking
selection, and fitting of amplification. Real-ear measures pro- (Delaroche, Thiebaut, and Dauman, 2004; Madell, 1988, 1995a,
vide good information about how much sound is reaching the 1998; Widen and Keener, 2003). Arousal responses, limb
eardrum, but this information is difficult to interpret without movements, and eye blinks frequently reveal suprathresh-
good information about the status of the infant’s unaided old level responses, but rarely threshold, since these behav-
hearing. Tonal ABR and ASSR measures provide some of this iors typically are elicited to louder stimuli. Sucking responses,
information but thresholds obtained may vary by  15 dB. however, although present at suprathreshold levels, are fre-
BOA techniques can assist in obtaining ear and frequency spe- quently observed at, or close to, threshold. Either initiation
cific information and can provide confirmation of information or cessation of sucking is an acceptable response. Some in-
obtained from electrophysiologic tests. fants will start sucking when a sound is presented, others
will cease sucking, and some will do both.

Pearl
♦ Diagnostic Audiologic Evaluation
of Neonates • Cessation or initiation of sucking is the only reliable re-
sponse for obtaining behavioral thresholds in infants
younger than 6 months.
The goal of an audiologic evaluation of an infant is usually
to determine if the child has sufficient hearing to develop
speech and language. A complete diagnostic evaluation of
Maximizing Observation of the Sucking Response
infants should include immittance testing to assess middle
ear status, and a test technique that will provide frequency Sucking can be observed with a bottle, nursing at the breast,
and ear specific information, ideally for both air and bone or with a pacifier. The family should be instructed to bring
conduction. The most common test protocols for evaluating the infant to the evaluation session hungry so that he will be
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6 Using Behavioral Observation Audiometry to Evaluate Hearing in Infants 57

ready to suck. The infant needs to be as comfortable as pos- the validity of the child’s response if it comes a long time af-
sible during testing, so, if the infant normally drinks from a ter presentation of the stimulus. With any test protocol, (be-
bottle, the family should bring one. If the infant normally havioral or electrophysiologic) responses can be accepted
nurses, it would be best if the infant is nursed during testing. only if they fall within a reasonable time window after pres-
For this test procedure to succeed, the mother has to be entation of the stimulus. Infants are fairly consistent, inter-
comfortable being observed nursing, and some women are nally. Some respond to the “on” of the stimulus and others
not. If the mother understands the reason for the intrusion respond to the “off.” The timing of the response is also usu-
on her privacy, she usually acquiesces. If the infant uses a ally consistent. Infants respond at about the same number of
pacifier, the family should bring one along. After the infant is seconds after presentation of the stimulus each time, with
finished eating, testing can frequently continue by observing the response time slightly shorter for louder stimuli (Madell,
sucking with a pacifier. If an infant is very hungry, it is best 1998; Northern and Downs, 2002; Thompson and Weber,
to allow him a little time to eat to enable him to get over 1974; Widen and Keener, 2003).
that initial extreme hunger before beginning testing.
As soon as the baby settles down, testing can begin. The
best way to observe the sucking response is to be able to see Positioning the Infant
the infant’s mouth close-up. A good view of the mouth can The necessity of appropriately positioning the infant cannot be
easily be obtained by having a video camera in the test overstated. Positioning may, in fact, be the most important
room that can be adjusted from the control room. By using factor in obtaining accurate test results with behavioral observa-
the zoom on the camera, it is possible to focus directly on tion audiometry. To obtain reliable test results, the infant needs
the infant’s mouth, which will enable the audiologist to to be resting in a comfortable position with full support of the
have an excellent view of sucking. If a camera is not avail- head and torso, and must be visible to the testers. If the child is
able, the audiologist needs to be certain that she can clearly nursing, the mother will be holding the child in her arms. If the
see changes in sucking to use this technique. child is using a bottle or a pacifier, the child may be held in
someone’s arms or placed in an infant seat (see Fig. 6–1A–C).
How Does One Know That the Sucking Is a Response The advantage of an infant seat is that the infant will not be re-
ceiving any “signals” from the mother when he hears the sound.
to a Sound Stimulus?
Involuntary movements such as stiffening by the mother in re-
As with all other behavioral responses, timing is the key fac- sponse to sound or movement of the breast or bottle can be
tor. When using play audiometry with a child, we question transmitted to the infant; therefore, changes in sucking may

Figure 6–1 Positioning the infant for testing: (A) using a bottle, (B) using a pacifier,
and (C) nursing at the breast.
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58 II Diagnosing Hearing Disorders in Infants and Children

occur that are not related to the auditory stimuli. If the infant is Testing Protocol of Behavioral Observation
being held, the mother or other person holding the infant Audiometry
should be very carefully instructed about the need to remain
silent and still throughout testing to eliminate interfering with Soundfield versus Earphone Testing
test results. It is sometimes useful to have the mother wear ear- A complete audiogram includes air and bone conduction
phones to prevent her from hearing and being influenced by the thresholds in each ear at frequencies of 250 to 8000 Hz.
sound; however, many mothers prefer not to wear earphones However, infants will provide only a limited number of re-
because they want to hear what their baby is hearing. sponses in one test session, so testing protocols need to be
designed to obtain the most information with the fewest re-
The Role of the Test Assistant sponses. The goal of the initial audiologic evaluation of an in-
fant is usually to be certain that the infant has sufficient
BOA is best accomplished by using two or more observers. hearing to develop speech and language. It may not be neces-
One is the audiologist controlling the test equipment, sary to obtain ear specific information at the first visit. (Occa-
usually outside of the room where the infant is placed. The sionally, a child is referred to a pediatric audiologist because
second observer typically is sitting next to the infant. Posi- of a medical condition that requires ear-specific information
tioning of all players needs to be carefully orchestrated to immediately, but this is more frequently the exception rather
be certain that both testers can easily see the infant. than the rule. When detailed information is required during
The test assistant has several responsibilities. He must the first test session, the test protocol will obviously have to
constantly be monitoring the infant to be certain that the change.) Ear specific information is important and must be
baby’s head and torso are comfortably balanced to minimize obtained prior to releasing an infant from audiologic follow-
or preclude fussing and straining. If the infant becomes up, but the more important question at the time of the initial
fussy, testing will need to stop until the infant can be made evaluation is, Does the infant hear enough to learn language?
comfortable (Madell, 1998). For older infants, or infants Should the initial audiologic evaluation indicate that hearing
using a bottle or a pacifier, the test assistant must keep the is normal in at least one ear utilizing soundfield testing, it
infant focused at the midline, again so that the infant is may not be critical to obtain information about each ear sep-
comfortable and not distracted. It is sometimes helpful to arately at that visit. However, if the initial testing indicates
hold a colorful toy (Madell, 1998) or an LED (light emitting that hearing is not within normal limits in the soundfield,
diode, usually a small red light) (Hicks, Tharpe, and Ashmead, then ear-specific information is critical so that management
2000; Olsho, 1987a) in front of the infant in a position that can proceed. No infant should be released from audiologic
allows the infant’s head to be centered. The toy should not follow-up until ear-specific information is obtained.
be held above the infant’s head so he needs to move his neck Under most conditions, testing should begin in soundfield.
to see it. Visual distractions need to be kept to a minimum Soundfield testing is less stressful for the infant and allows
(Muir, Clifton, and Clarkson, 1989) to be certain that extra- two ears to be stimulated at the same time. This ensures test-
neous stimuli are not interfering with observation of re- ing of the best hearing ear. It also permits parents to hear the
sponses. It is important that the person holding the toy or sounds; this can be very useful in their understanding of the
LED make no change in the movement of the toy when the test results. Earphone testing can follow later in the initial
sound is presented. Any change in movement can confound test session, or in a subsequent test session. When earphone
the interpretation of whether the infant is responding to the testing is being attempted, insert earphones are the ear-
sound or to the change in the distracter. If the infant is in an phones of choice for infants. Insert earphones (Fig. 6–2) will
infant seat, the test assistant may be the one holding the remain appropriately seated in the ear canal and will provide
bottle or pacifier and holding the visual distracters. Finally, the most accurate results in tiny ears. Circumaural earphones
the test assistant will be one of the observers who judges are frequently too large and are very difficult to keep in place.
whether or not the infant responded to the sound presenta- If testing indicates thresholds at lower than normal hear-
tion by changing his or her sucking behavior. ing levels, bone conduction testing is essential. The bone vi-
brator should be held in place with either a pediatric sized
The Role of the Parents headband, or a fabric one that goes around the head and
across the forehead using Velcro to secure it in place. If a
The parents cannot be relied on as observers. Their stakes are metal headband is used, soft material such as foam or other
too high, they are not experienced in the task, and they may padding should be used for comfort and to keep the head-
not understand exactly what constitutes an acceptable re- band from moving. If a hearing loss is confirmed, the same
sponse. Parents are, however, very valuable in helping the test protocols can be used to assess functional gain with
testers to understand the baby and assisting in making the amplification in soundfield.
baby comfortable. At least one parent needs to be in the test
room to assist in understanding the test protocols and test
results. If both parents are present, the other parent can ob-
Test Stimuli
serve from the control room. The audiologist in the control
room can point out responses during testing to assist in the When planning the test session, it is important to keep in
parent’s understanding of the tests. Their observation of how mind that infants will provide only a limited number of
the baby does or does not respond will be helpful when in- responses; and so each stimulus presentation must be consid-
terpreting the final test results and presenting subsequent ered carefully. The goal of the testing is to obtain frequency-
follow-up recommendations (Flasher and Fogel, 2004). specific test results. Warble tones or narrow bands of noise
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6 Using Behavioral Observation Audiometry to Evaluate Hearing in Infants 59

may be better at low frequencies, so testing should begin

with 500 Hz. After obtaining thresholds at 500 and 2000
Hz, make a determination about what is the next most im-
portant piece of information to have. For example, if
thresholds at both 500 and 2000 Hz are normal, it would
be more important to obtain a threshold at 4000 Hz than at
1000 Hz, since hearing is likely also to be normal at 1000
Hz. However, if hearing at 500 Hz is at 30 dB HL and hear-
ing at 2000 Hz is at 70 dB HL, it would be very important to
know what hearing is at 1000 Hz.
Several indications can clue the audiologist about which
frequencies and intensities should be used to begin testing:

♦ Observe the infant’s responses to noisemakers.

♦ Observe the infant’s responses to voice and environmen-
tal sounds.
♦ Question the parents about the infant’s response to
Figure 6–2 Infant with insert earphones.
sound before testing.

Presentation of stimuli should begin at a soft level

will provide this information. Broadband stimuli such as mu- slightly above where you expect the infant to respond, and
sic, conversational speech, or white noise will not. Narrow then be increased in 10-dB steps until a response is ob-
bands of noise are frequently easier for an infant to respond to served. The initial stimulus should not be so loud as to star-
(Gravel, 2000; Madell 1998), and may provide thresholds that tle the infant. If the initial stimulus is much louder than
are 5 to 10 dB softer than those obtained with warble tones. threshold, it may be difficult to regain the infant’s attention
Speech awareness thresholds to low (ba), mid-high (sh), to threshold-level stimuli. When the infant responds, de-
and high (s) frequency speech stimuli can be used to crease intensity in 10-dB steps, decreasing stimuli in 5-dB
confirm warble tone/noise band thresholds. The threshold steps when close to estimated threshold, and then increase
for “ba” should be close to the threshold obtained intensity in 5- or 10-dB steps as would be done with any
at 500 Hz, “sh” should be close to the threshold obtained at other population. Especially with infants, no response
2000 Hz, and “s” should be close to the threshold obtained should be recorded until it is observed at the same level
at 3000 to 4000 Hz (Ling, 2002; Madell, 1995b, 1998). three times.
Timing is critical. If stimuli are presented too quickly, the
infant will ignore them. A sound that comes out of silence is
Presentation of Test Stimuli
more likely to elicit a response. To obtain reliable responses,
Many normal hearing infants respond better to high-fre- it is important to observe the infant carefully. If an infant
quency stimuli, so it is reasonable to begin at a high fre- startles to a sound, it is probably significantly above thresh-
quency, usually 2000 Hz. To explain, if there is concern old. The way the baby responds when the stimulus is loud
about middle ear pathology, low-frequency hearing could will provide clues about the type of response and latency
be compromised, so it may be better to begin with a high- that can be expected. This information can be used to inter-
frequency stimulus (2000 Hz). On the other hand, if a sig- pret responses when the stimulus intensity decreases
nificant sensorineural hearing loss is suspected, hearing (Table 6–1).

Table 6–1 Behavioral Observation Audiometry Test Protocol

1. Bring infant into test room in hungry state.

2. Seat infant so torso is supported and infant is not fidgety, and so tester(s) can easily see mouth.
3. Monitor infant state during testing and stop if infant becomes fidgety.
4. Instruct parents not to respond to test stimuli or responses from the child.
5. Test assistant will keep infant centered, observe responses, and monitor parents’ behavior.
6. Begin testing in soundfield.
7. Begin testing with a stimulus that is slightly above estimated threshold.
8. Test one low (500 Hz) and one high (2000 Hz) frequency initially and select additional frequencies to test depending on initial responses.
9. Reduce thresholds in 10-dB steps and increase in 5- to 10-dB steps to bracket threshold. Record a response after three reversals.
10. Take breaks as needed to calm the infant and increase usable test time.
11. If soundfield testing indicates a hearing loss, test bone conduction.
12. If infant is still responding, or at the next test session, test with insert earphones.
13. Test with technology as needed.
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60 II Diagnosing Hearing Disorders in Infants and Children

Other Factors That Influence Behavioral Observation

Audiometry Test Results with Infants
The audiologist must know something about the infant to
obtain reliable test results. Spending a little time with the
infant before beginning testing will increase the likelihood
of obtaining reliable test results. It is important to have a
good estimate of the infant’s developmental, neurologic,
and behavioral status. Can the infant do whatever is
required for testing? If we are looking for sucking changes,
we need to know that the infant sucks steadily. Some
infants take a few sucks and stop, then start again. When
an infant has an irregular sucking pattern, it becomes very
difficult to use sucking to assess hearing. Some infants,
because of serious medical conditions, will be fed with a
gastrointestinal tube. If the infant uses a pacifier, it may
still be possible to test hearing by measuring nonnutritive
sucking responses. However, if the infant does not use a
Figure 6–3 Position of infant for observation audiometry.
pacifier, it will not be possible to measure hearing using
a sucking technique.
Are there concerns about the infant’s neurologic status
that could affect testing? For example, is the child alert to as a response. Changing response criteria during testing runs
the environment? A baby may indicate visual and tactile the risk of accepting behaviors as responses that are not ac-
awareness by making postural changes and meaningful eye- tually responses. The response must be time-locked to the
gaze to people and environmental events. In a visually alert presentation of the stimulus. All of the infant’s responses
baby, lack of response to sound is strongly suggestive of a must be repeatable. The use of multiple observers to deter-
true hearing loss. However, if the infant is not alert to visual mine if a response is present also will increase reliability, as
or tactile stimuli, an inability to respond to auditory stimuli will the use of silent controls (Gravel and McCaughey, 2004).
may not be an indication of hearing loss.

Comparison of Behavioral Observation Audiometry

Adding Objectivity to Behavioral Observation Thresholds to VRA, CPA, and ABR
Audiometry
By carefully following the sucking test protocols detailed
The Test Setting in this chapter, and observed on the accompanying DVD,
observation responses can be used to obtain reliable
Infant State and Positioning thresholds. Figs. 6–4A–D are typical of many multiple
Monitor the infant’s state to increase the likelihood that it audiograms which demonstrate that thresholds can be ob-
will be possible to accurately observe responses. State refers tained accurately by using BOA. These audiograms make
to the infant’s level of arousal, from deep sleep to hysterical the best possible case for the reliability of the BOA suck-
crying (Fig. 6–3). ing technique by comparing thresholds obtained with
BOA, VRA, and play audiometry over several years on four
Movement of Test Assistant and Parent/Caregiver children. Work is currently being conducted at our center
on infants referred for hearing evaluation after failing
Everyone in the test room with the child must newborn hearing screening or referred by parents because
of family history or concern about the infants’ responses
♦ be still and nonresponsive to the test stimuli to sound. Results indicate that BOA, appropriately con-
♦ keep the infant focused at midline ducted, using the sucking paradigm discussed in this
chapter, can accurately identify hearing levels in infants
♦ be reminded not to respond to the stimulus by altering when compared to ABR thresholds.
the movement of the toy or facial expressions

Test Stimuli and Response Developing Comfort Using Behavioral Observation

Audiometry
The most critical element in obtaining reliable responses is to
predetermine what will constitute a response (Flexer and Clinicians who are comfortable using ABR to assess infants
Gans, 1986; Madell, 1998; Widen, 1993). If it has been may want to add BOA to their protocol to gain experience
decided that sucking is the acceptable response, the audiolo- with the technique before making behavioral testing a regu-
gist should not then also accept eye widening or a head turn lar part of clinical practice. As with most other skills, it
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6 Using Behavioral Observation Audiometry to Evaluate Hearing in Infants 61

Figure 6–4 (A–D) Comparison of thresholds

with behavioral observation (BOA), visual
reinforcement (VRA), and play audiometry.
(Continued)
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62 II Diagnosing Hearing Disorders in Infants and Children

Figure 6–4 (Continued) (A–D)

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6 Using Behavioral Observation Audiometry to Evaluate Hearing in Infants 63

takes experience to become a competent tester when using

Discussion Topics
the BOA sucking paradigm detailed in this chapter. It is im-
portant to be certain that the test situation is appropriately
1. Discuss why behavioral observation audiometry has not been
organized so as to maximize the ability to observe changes
considered a good clinical tool in the past.
in sucking. The clinicians should have good communication
with each other to enable them to share information during 2. Discuss why sucking is a more reliable threshold response
testing. All infant responses should be repeatable. Viewing when testing infants.
the DVD that accompanies this book will be helpful in
3. Discuss ways to maximize objectivity in BOA.
developing the necessary BOA skills.

References

Apuzzo, M. L., and Yoshinaga-Itana, C. (1995). Early identification of infants Hicks, C. B., Tharpe, A. M., and Ashmead, D. H. (2000). Behavioral auditory
with significant hearing loss and the Minnesota Child Development In- assessment of young infants: methodological limitations or natural lack
ventory. Seminars in Hearing, 16, 124–139. of auditory responsiveness? American Journal of Audiology, 9, 124–130.
American Speech-Language-Hearing Association. (2004). Guidelines for Jerger, J. F., and Hayes, D. (1976). The cross-check principle in pediatric au-
the Audiologic Assessment of Children from Birth to 5 Years of Age. diometry. Archives of Otolaryngology, 102, 614–620.
www.asha.org/members/deskref-journals/deskref/default.
Ling, D. (2002). Speech and the hearing impaired child. (2nd ed.) Washington,
Berg, K. M., and Smith, M. C. (1983). Behavioral thresholds of tones during DC: Alexander Graham Bell Association of the Deaf and Hard of Hearing.
infancy. Journal of Experimental Child Psychology, 35, 409–425.
Madell, J. R. (1988). Identification and treatment of very young children
Bess, F. H., and Humes, L. E. (2003). Audiology: the fundamentals. 3rd ed. with hearing loss. Infants and Young Children, 1, 20–30.
Philadelphia: Lippincott Williams & Wilkins.
Madell, J. R. (1995a). Behavioral evaluation of infants after hearing screen-
Bove, C., and Flugrath, J. M. (1973). Frequency components of noisemakers ing: Can it be done? Hearing Instruments, 12, 4–8.
for use in pediatric audiological evaluations. Volta Review 75, 551–556.
Madell, J. R. (1995b). Speech audiometry for children. In S.E. Gerber (Ed.) Pedi-
Delaroche, M., Thiebaut, R., and Dauman, R. (2004). Behavioral audiometry: atric audiology (pp. 84–103). Washington, DC: Gallaudet University Press.
protocols for measuring hearing thresholds in babies aged 4–18 months.
Madell, J. R. (1998). Behavioral evaluation of hearing in infants and young
International Journal of Pediatric Otorhinolaryngology, 68, 1233–1243.
children. New York: Thieme.
Downs, M. P., and Sterritt, G. M. (1964). Identification audiometry for
McConnell, F., and Ward, P. (1967). Deafness in childhood. Nashville: Van-
neonates: a preliminary report. Journal of Auditory Research, 4, 69–80.
derbilt University Press.
Downs, M. P., and Sterritt, G. M. (1967). A guide to newborn and infants
Mencher, G. T., McCullouch, B., Derbyshire, A.J ., and Dethlefs, R. (1977).
hearing screening. Archives of Otolaryngology, 85, 15–22.
Observer bias as a factor in neonatal hearing screening. Journal of
Eisele, W. A., Berry, R. C., and Shriner, T. H. (1975). Infant sucking response Speech and Hearing Research, 20, 27–34.
patterns as a conjugate function of change in the sound pressure level of Muir, D. W., Clifton, R. K, and Clarkson, M. G. (1989). The development of a
auditory stimuli. Journal of Speech and Hearing Research 18, 296–307. human auditory localization response: a U-shaped function. Canadian
Eisenberg, R. B. (1969). Auditory behavior in the human neonate: func- Journal of Psychology, 43, 199–216.
tional properties of sound and their ontogenetic implications. Interna- Northern, J., and Downs, M. (1974). Hearing in children. Baltimore:
tional Audiology, 8, 34–45. Williams and Wilkins.
Ewing, J. R., and Ewing, A. W. G. (1940). Discussion on audiometric tests Northern J., and Downs, M. (1984). Hearing in children. Baltimore:
and the capacity to hear speech. Journal of Laryngology and Otology, 55, Williams and Wilkins.
339–355.
Northern, J., and Downs, M. (1991). Hearing in children. 4th ed. Baltimore:
Ewing, J. R., and Ewing, A. W. G. (1944). The ascertainment of deafness in Williams and Wilkins.
infancy and early childhood. Journal of Laryngology and Otology, 54,
309–333. Northern, J. L., and Downs, M. P. (2002). Hearing in children. 5th ed. Balti-
more: Lippincott Williams & Wilkins.
Flasher, L. V., and Fogel, P. T. (2004). Counseling skills for speech-language
pathologists and audiologists. Clifton Park, NY: Delmar Learning. Nozza, R. (2006). Developmental psychoacoustics: auditory function in in-
fants and children. Paper presented at the 4th Widex Congress of Paedi-
Flexer, C., and Gans, D. P. (1986). Distribution of auditory response behav- atric Audiology, Ottawa, Canada, May 19–21, 2006.
iors in normal infants and profoundly multihandicapped children. Jour-
nal of Speech and Hearing Research, 29, 425–429. Olsho, L. W. (1984). Infant frequency discrimination. Infant Behavior and
Development, 7, 27–35.
Frisina, R. (1963), Measurement of hearing in children. In J.F. Jerger, (Ed.),
Modern developments in audiology, New York: Academic. Olsho, L. W., Koch, E. G, Halpin, C. F., and Carter, E.A. (1987a). An observer-
based psychoacoustic procedure for use with young infants. Develop-
Froeschels, E., and Beebe, H. (1946). Testing the hearing of the newborn. mental Psychology, 23, 627–640.
Archives of Otolaryngology, 44, 710–714.
Olsho, L. W., Koch, E. G., and Halpin, C. F. (1987b). Level and age effects in
Gerber, S. E. (1977). Audiometry in Infancy. New York: Grune and Stratton. infant frequency discrimination. Journal of the Acoustical Society of
America, 82, 454–464.
Gravel, J. (2000) Audiologic assessment for the fitting of hearing instruments:
big challenges from tiny ears. In R. Seewald (Ed). A sound foundation Olsho, L. W., Koch, E. G., Carter, E. A., Halpin, C. F., and Spetner, N. B. (1988).
through early amplification. Proceedings of an International Conference, Pure tone sensitivity of human infants. Journal of the Acoustical Society
Vanderbilt-Bill Wilkerson Press, Phonak, AG, Nashville, TN, 2000, pp. 33–46. of America, 84, 1316–1324.
Gravel, J. S., and McCaughey, C. C. (2004). Family-centered audiologic as- Poblano, A., Chayo, I., Ibarra, J., and Reuda, E. (2000). Electrophysiological
sessment for infants and young children with hearing loss. Seminars in and behavioral methods in early detection of hearing impairment.
Hearing, 25, 309–317. Archives of Medical Research, 31, 75–80.
c06.qxd 2/13/08 8:55 PM Page 64

64 II Diagnosing Hearing Disorders in Infants and Children

Sharma, A., Dorman, M. F., and Spahr, A. J. (2002). A sensitive period for White, K. R., Maxon, A. B., Behrens, T. B., Blackwell, P. M., and Vohr, B. R.
the development of the central auditory system in children with (1992). Neonatal screening using evoked otoacoustic emissions: the
cochlear implants: implications for age of implantation. Ear and Hear- Rhode Island hearing assessment project. In F. H. Bess and J. W. Hall III
ing, 23, 532–539. (Eds). Screening children for auditory function. Nashville: Bill Wilkerson
Center Press.
Sininger, Y. S. (1993). Evaluation of hearing in the neonate using the audi-
tory brainstem response. Consensus Development Conference on Early White, K. R.,Vohr, B. R., and Behrens, T. B. (1993). Universal newborn
Identification of Hearing impairment in Infants and Young Children, (pp. screening using transient evoked otoacoustic emissions: results of the
95–97). Bethesda: National Institutes of Health. Rhode Island hearing assessment project. Seminars in Hearing, 14,
18–29.
Thompson, M., and Thompson, F. (1972). Response of infants and young
children as a function of auditory stimuli and test method. Journal of Widen, J. E. (1993). Adding objectivity to infant behavioral audiometry. Ear
Speech and Hearing Research, 15, 699-707. and Hearing, 14, 49–57.

Weber, B. A. (1969). Validation of observer judgments in behavioral obser- Widen, J. E., and Keener, S. (2003) Diagnostic testing for hearing loss in in-
vation audiometry. Journal of Speech and Hearing Research, 34, fants and young children. Mental Retardation and Developmental Dis-
350–355. abilities Research Reviews, 9, 220–224.

Wedenberg, E. (1956). Auditory tests on newborn infants. Acta Otolaryngo- Yoshinaga-Itana, C, Couter, D., and Thomson, V. (2001) Developmental out-
logica, 46, 446–461. comes of children with hearing loss born in Colorado hospitals with and
without universal newborn hearing screening programs. Seminars in
Werner, L., and Gillenwater, J. (1990). Pure tone sensitivity of 2-5 week old Neonatology, 6, 521–529.
infants. Infant Behavior and Development, 13, 355–375.